A Model Policy

Without
a doubt, the physical environment of central sterile (CS) helps preserve
sterility of the instruments before, during and after they are processed and
wrapped. Slipshod housekeeping can recontaminate instruments and induce peril in
the operating room. On the other hand, diligent cleaning in the work area
retains trust in the department. Overall, it is uncommon for infections to come
from central sterile.

"Less than 1 percent of all post-op infections can be traced back to
sterile processing," says Jackie Sandridge, RN, CNOR, supervisor of central
sterile supply for Martha Jefferson Hospital in Charlottesville, Va. "You
seldom hear of nightmares coming out of sterile processing, unless instruments
were not sterilized before they left the department. There is always that
potential, (but) by the time the instruments go into the sterilization process,
they have been rendered safe for handling. Most of the bioburden would have been
washed away with the chemicals in the rinse process of the
decontaminators."

Finding someone who is dedicated to cleaning central sterile was a big hurdle
for Sandridge, but she lucked out by finding a gentleman on the housekeeping
staff who cleans every evening and takes pride in his work. Additionally, the
central sterile staff wipes surfaces as needed throughout the day.

"The floors in decontam, processing and sterile storage are cleaned
every night," shares Sandridge. "We do not flood them, but they are
wet mopped by the housekeeping staff, which is trained by a housekeeping
supervisor who follows written policies and procedures for cleaning this
department."

The routine at Martha Jefferson Hospital includes vents being dusted and
other horizontal surfaces above shoulder height, like ledges around doors, being
cleaned on Monday. On Tuesday, housekeeping vacuums under worktables and wet
mops. Sinks are cleaned and sanitized daily.

During processing, dust particles in an instrument set being sterilized can
still have an infection from a foreign body reaction, says Sandridge. "All
dust, foreign flakes or a hair from under your cap has to be cleaned up on a
daily basis. You can have infections from sterile foreign bodies. I don't know
of any documentation, but if your hospital has a very low infection and
cross-contamination rate, it would be because you have a spic-and-span sterile
processing department."

Divide and Conquer

Similar to the Martha Jefferson Hospital, the VA Medical Center in Ann Arbor,
Mich., divides the cleaning responsibilities in CS. "Countertops and
shelves are done by our own people (and) floors, walls, ceilings and air vents
are supposed to be done by the Environmental Management Service (EMS),"
says Kurt Browne, chief of the sterile processing department. "I am the one
who complains, but I am not the one who can make sure it gets done. I buddy up
with the infection control people and they help a lot. The relationship is
critical because they will go to the industrial hygienist to (get things
done)."

Airflow can be difficult to control at the VA Medical Center, says Browne.
"The CS department has no control over the filters and if engineering is
not changing filters on a timely basis, we get dirty air."

Browne emphasizes the need for positive pressure in the prep room and
negative pressure in decontam. "Engineering or industrial hygiene is
responsible for recording on a weekly or monthly basis that the room is negative
pressure," he says.

Browne
has been known to call in his own people for a more thorough cleaning job in CS.
"Otherwise it doesn't get done the way it needs to be done," he says.
"The trouble is the impression people have of CS being the dishwashing
department vs. a department that supports surgery. They have a difficult time
seeing the relationship between the instruments that get processed here and the
patient on the table in the operating room." He finds that proper training
stresses the importance of CS and helps his staff understand its relationship
with the OR.

Employees also are taught to move from the cleanest area to the dirtiest area
in CS, not vice versa. "It is to avoid having employees change clothes to
go into a cleaner area and avoid cross-contamination."

Pat Pratt, central service lead hand for Renfrew Victoria Hospital in
Ontario, Canada, agrees that to keep an area clean, the staff doesn't traverse
from a dirty area to the clean area. "It is a constant challenge to keep
everything in the right area," she says.

Since Renfrew does not have enough staff to set up a proper decontam area,
everybody is responsible for keeping central sterile clean. "When we go
into that area, we put on protective clothing, gloves and aprons and when we
leave, they are removed," says Pratt. "Handwashing helps ensure we
don't spread anything. We have a pass-through from the dirty area to the clean
area. Everything that is washed is passed through to the clean area and it is
packaged on that side."

Following the Central Service Supply guidelines and AORN as best they can,
Pratt and her staff do well in many areas of central sterile despite physical
and staffing considerations that prevent them from meeting the guidelines
precisely. "I have worked here about 20 years and we never had an infection
traced back to our department," says Pratt. "Housekeeping cleans the
floors and our bathroom. The counters and shelves we do ourselves weekly or as
needed. Two or three times a year, housekeeping washes all the walls, floors,
vents and windows."

Twenty years ago, says Pratt, people didn't really know what to do.
"There were no courses, just on-the-job training," she says.
"Consequently, if the trainer made mistakes, you tended to make the same
ones. Now our Central Services Association puts out an all-encompassing course
that our employees have to take, which trains them in the proper way to do
things. We try very hard to improve as best we can. If you don't have the proper
environment, you can't guarantee what you are putting out."

A Model Policy

Following is a section of VA policy 7176 addressing the requirements for
supply, processing and distribution (SPD) within the VA system as provided by
Kurt Browne, chief of the sterile processing department.

"In cooperation with Environmental Management Service (EMS), a written
daily cleaning schedule for SPD areas will be developed, implemented and
enforced. Cleaning encompasses wet mopping or wet vacuuming of floors with a
suitable germicide at least once a day and more often if necessary. Walls,
ceilings, vents and filters should be cleaned at least monthly. Sweeping or dry
dusting is prohibited in SPD. Dedicated cleaning equipment will be provided for,
and maintained in, the SPD decontamination area. This equipment will not be used
in other areas of SPD or the facility. Dedicated sanitation/cleaning materials
will be used in the clean areas of SPD. There will be written procedures for the
cleaning and sanitizing of work surfaces, floors, utensils and equipment used in
SPD functions. EMS personnel will never go from the decontamination area to the
preparation area while cleaning. Cleaning should start in the sterile storage
area, proceed to the preparation area and then to the decontamination
area."